Tailoring Care to Vulnerable Populations By Incorporating Social Determinants of Health: The Veterans Health Administration’s “Homeless Patient Aligned Care Team” Program
Although the clinical consequences of homelessness are well described, less is known about the role for healthcare systems in improving clinical and social outcomes for the homeless. We described the national implementation of a “homeless medical home” initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites.
We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific healthcare performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute healthcare services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services.
More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies.
Integrating social determinants of health into clinical care can be effective for high-risk homeless veterans.
Overview of article
- Little is known about the role of health care systems in improving clinical and social outcomes for the homeless. Researchers sought to fill this gap by implementing a homeless medical home initiative in 33 facilities at the Veterans Health Administration (VHA) with homeless medical homes and patient-aligned care teams that served more than 14,000 patients
- The Homeless Patient Aligned Care Team (H-PACT) program integrated and coordinated health and social services care for homeless veterans following implementation in 2011. It was designed from lessons learned from Healthcare for Homeless Program and theoretic framework of the Behavioral Model for Vulnerable Populations
- The goals of model: 1) Engage the patient in health care; 2) Stabilize them clinically; 3) Provide them with needed social services and programs; and 4) Expedite their placement in housing
- The core elements of model: 1) Enhanced, low-threshold access to care with open-access, walk-in capacity, flexible scheduling (e.g., building in scheduling buffers to account for unreliable transportation), and clinical outreach to homeless people on the street or in community locations (e.g., shelter, soup kitchen); 2) medical services and sustenance needs (e.g., food vouchers, clothes, bus passes) are available at the same location (i.e., colocation); 3) health care management is integrated with community agencies; 4) ongoing staff training and development of homeless care skills; and 5) data-driven accountable care processes
- The model includes 3 implementation phases: 1) Identification and referral (to ER, inpatient ward, to community services) of patients; 2) Treatment engagement, including tailored, destigmatized care that is integrated on-site; and 3) Stabilization through chronic disease management, prevention of recidivism, and early identification of new needs
- The H-PACT model collected the following: 1) Implementation checklists that detailed implementation of H-PACT model phases; and 2) annual survey that assesses access to care strategies, team capacity and availability, and integration of homeless monitoring (process for tracking homeless participant housing status), integration of social services and supports (i.e., food assistance, clothing, hygiene, transportation) into on-site care, and team’s work in community outreach
- Monthly site-specific reports were sent to indicate the following: 1) Panel growth ( measurement of site’s availability to engage and retain homeless veteran’s in care model); 2) Patient complexity (measured by diagnostic cost group (DCG), and service use patterns); 3) Average number of visits per patient per each service period; and 4) Net reductions in ED use and hospital admissions (comparing enrollment 6 months before and after enrollments)
- More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an onsite clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. 6-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19% reduction in emergency department use and a 34.7% reduction in hospitalizations
- 3 features were significantly associated with high performance: 1) Higher staffing ratios than other sites; 2) Integration of social supports and social services into clinical care; and 3) Outreach to and integration with community agencies
- Area for future research: 1) Better understanding patient perspective as it relates to the impact of care on health outcomes
- Findings suggest that critical elements of high performance in a QIC program such as this are robust incorporation of social determinant programs into clinical care delivery, dedicated staff time, and community integration
- The following are key drivers of findings: 1) Having the capacity to address subacute needs on demand in ambulatory settings; and 2) Integrating social services and supports and housing resources and assistance into the clinical model provides a holistic approach to patient care and addresses the underlying causes for much of acute care use